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Research & Scholarship

Current Research and Scholarly Interests

One of my research focuses is in immigrant and minority child health, with a primary focus on Latino children. My research has explored the health status of Latino children by examining their growth patterns, prevalence of chronic illness, perceptions of health, and their access to health care. Currently, I am examining the health and development of children in immigrant families, with a particular focus on children 0 to 5 years.

Another research interest is in diversity in the health professions; particularly in the area of pediatrics. Children are the most diverse component of the U.S. populations and suffer health disparities partially based on their diverse backgrounds.Developing a diverse pediatric workforce is necessary for the provision of effective health care. This includes the development of effective pipeline, leadership programs, and effective cultural competency curriculum.

Publications

Journal Articles

Abstract

This study examined the early developmental context of children in immigrant families (CIF), measured by the frequency with which parents share books with their children.Trends in the frequency with which parents report book sharing, defined in this analysis as reading or sharing picture books with their young children, were analyzed across immigrant and nonimmigrant households by using data from the 2005, 2007, and 2009 California Health Interview Survey. Stepwise multivariate logistic regression assessed the likelihood that CIF shared books with parents daily.In this study, 57.5% of parents in immigrant families reported daily book sharing (DBS), compared with 75.8% of native-born parents. The lowest percentage of DBS was seen in Hispanic families with 2 foreign-born parents (47.1%). When controlling for independent variables, CIF with 2 foreign-born parents had the lowest odds of sharing books daily (odds ratio [OR]: 0.61; 95% confidence interval [CI]: 0.54-0.68). When stratified by race/ethnicity, separate multivariate logistic regressions revealed CIF status to be associated with lower odds of DBS for Asian (OR: 0.56; 95% CI: 0.38-0.81) and Hispanic CIF (OR: 0.49; 95% CI: 0.42-0.58).There is an association between the lower odds of DBS and parental immigrant status, especially for Hispanic and Asian children. This relationship holds after controlling for variables thought to explain differences in literacy-related practices, such as parental education and income. Because book sharing is central to children's development of early literacy and language skills, this disparity merits further exploration with the aim of informing future interventions.

Abstract

One in 10 US adults of childbearing age has limited English proficiency (LEP). Parental LEP is associated with worse health outcomes among healthy children. The relationship of parental LEP to health outcomes for children with special health care needs (CSHCN) has not been systematically reviewed.To conduct a systematic review of peer-reviewed literature examining relationships between parental LEP and health outcomes for CSHCN.PubMed, Scopus, Cochrane Library, Social Science Abstracts, bibliographies of included studies. Key search term categories: language, child, special health care needs, and health outcomes.US studies published between 1964 and 2012 were included if: 1) subjects were CSHCN; 2) studies included some measure of parental LEP; 3) at least 1 outcome measure of child health status, access, utilization, costs, or quality; and 4) primary or secondary data analysis.Three trained reviewers independently screened studies and extracted data. Two separate reviewers appraised studies for methodological rigor and quality.From 2765 titles and abstracts, 31 studies met eligibility criteria. Five studies assessed child health status, 12 assessed access, 8 assessed utilization, 2 assessed costs, and 14 assessed quality. Nearly all (29 of 31) studies used only parent- or child-reported outcome measures, rather than objective measures. LEP parents were substantially more likely than English-proficient parents to report that their CSHCN were uninsured and had no usual source of care or medical home. LEP parents were also less likely to report family-centered care and satisfaction with care. Disparities persisted for children with LEP parents after adjustment for ethnicity and socioeconomic status.Parental LEP is independently associated with worse health care access and quality for CSHCN. Health care providers should recognize LEP as an independent risk factor for poor health outcomes among CSHCN. Emerging models of chronic disease care should integrate and evaluate interventions that target access and quality disparities for LEP families.

Abstract

To describe the diversity of pediatric residents and examine relationships of cross-cultural training experiences with training satisfaction, perceived preparedness for providing culturally effective care, and attitudes surrounding care for underserved populations.A cross-sectional survey was conducted of a national random sample of graduating pediatric residents and an additional sample of minority residents. Using weighted analysis, we used multivariate regression to test for differences in satisfaction, preparedness, and attitudes between residents with more and less cross-cultural experiences during residency, controlling for residents' characteristics and experiences before training.The survey response rate was 57%. Eleven percent were Hispanic, 61% white, 21% Asian, 9% African American, 9% other racial/ethnic groups; 34% grew up in a bi- or multilingual family. Ninety-three percent of residents were satisfied with their residency training, 81% with the instruction they received on health and health care disparities, and 54% on global health issues. Ninety-six percent of residents felt they were prepared to care for patients from diverse backgrounds, but fewer felt prepared to care for families with beliefs at odds with Western medicine (49%) and families who receive alternative or complementary care (37%). Residents with more cross-cultural experiences during residency reported being better prepared than those with less experience to care for families with limited English proficiency (adjusted odds ratio [aOR] 2.11; 95% confidence interval [CI] 1.40-3.17), new immigrants (aOR 1.91; 95% CI 1.32-2.75), and with religious beliefs that might affect clinical care (aOR 1.62; 95% CI 1.13-2.32).Pediatric residents begin their training with diverse cross-cultural backgrounds and experiences. Residency experiences in cross-cultural care contribute to feelings of preparedness to care for diverse US children.

Abstract

To compare health care access, utilization, and perceived health status for children with SHCN in immigrant and nonimmigrant families. This cross-sectional study used data from the 2003 California Health Interview Survey to identify 1404 children (ages 0-11) with a special health care need. Chi-square and logistic regression analyses were used to examine relations between immigrant status and health access, utilization, and health status variables. Compared to children with special health care needs (CSHCN) in nonimmigrant families, CSHCN in immigrant families are more likely to be uninsured (10.4 vs. 4.8%), lack a usual source of care (5.9 vs. 1.9%), report a delay in medical care (13.0 vs. 8.1%), and report no visit to the doctor in the past year (6.8 vs. 2.6%). They are less likely to report an emergency room visit in the past year (30.0 vs. 44.0%), yet more likely to report fair or poor perceived health status (33.0 vs. 16.0%). Multivariate analyses suggested that the bivariate findings for children with SHCN in immigrant families largely reflected differences in family socioeconomic status, parent's language, parental education, ethnicity, and children's insurance status. Limited resources, non-English language, and limited health-care use are some of the barriers to staying healthy for CSHCN in immigrant families. Public policies that improve access to existing insurance programs and provide culturally and linguistically appropriate care will likely decrease health and health care disparities for this population.

Abstract

Filipino Americans have more adolescent pregnancies than other Asian-Pacific Islanders (APIs). Few community-academic collaborations have addressed adolescent pregnancy prevention in this community.We sought to describe the lessons learned from and impact of a community-based teen pregnancy prevention program for Filipino Americans implemented by a Filipina pediatrics resident.We formed a community-academic partnership between the Filipino Youth Coalition, a community-based organization (CBO) in San Jose, California, and the Stanford School of Medicine's Pediatric Advocacy Program. We developed a culturally tailored parent-teen conference addressing adolescent pregnancy prevention in Filipino Americans. We qualitatively and quantitatively evaluated this intervention by collecting both pre- and post-conference data using a convenience sample design.Engaging particular aspects of Filipino culture (i.e., religion and intergenerational differences) helped to make this community-academic partnership successful. For physicians-in-training who are conducting community-based participatory research (CBPR), project challenges may include difficulties in building and maintaining academic- community relationships, struggles to promote sustainability, and conflicting goals of "community insiders" and "academic outsiders." Authors offer insights and implications for residents interested in practicing CBPR.CBPR is a key tool for exploring health issues in understudied populations. CBPR experiences can provide meaningful educational opportunities for physicians-in-training and can build sustained capacity in CBOs. They can also help residents to develop analytic skills, directly affect the health of the communities they serve, and, for minority physicians, give back to the communities they call home.

Health disparities and children in immigrant families: a research agenda.PediatricsMendoza, F. S.2009; 124: S187-95

Abstract

Children in immigrant families now comprise 1 in 5 children in the United States. Eighty percent of them are US citizens, and 53% live in mixed-citizenship families. Their families are among the poorest, least educated, least insured, and least able to access health care. Nonetheless, these children demonstrate better-than-expected health status, a finding termed "the immigrant paradox" and one suggesting that cultural health behaviors among immigrant families might be protective in some areas of health. In this article the strength of the immigrant paradox, the effect of acculturation on health, and the relationships of acculturation, enculturation, language, and literacy skills to health disparities are reviewed. The current public policy issues that affect the health disparities of children of immigrant families are presented, and a research agenda for improving our knowledge about children in immigrant families to develop effective interventions and public policies that will reduce their health disparities is set forth.

Abstract

Despite their high levels of poverty and less access to health care, children in immigrant families have better than expected health outcomes compared with children in nonimmigrant families. However, this observation has not been confirmed in children with chronic illness. The objective of this study was to determine whether children with asthma in immigrant families have better than expected health status than children with asthma in nonimmigrant families.Data from the 2001 and 2003 California Health Interview Survey (CHIS) were used to identify 2600 children, aged 1 to 11, with physician-diagnosed asthma. Bivariate analyses and logistic regression were performed to examine health care access, utilization, and health status measures by our primary independent variable, immigrant family status.Compared with children with asthma in nonimmigrant families, children with asthma in immigrant families are more likely to lack a usual source of care (2.6% vs 1.0%; P < .05), report a delay in medical care (8.9% vs 5.2%; P < .01), and report no visit to the doctor in the past year (7.0% vs 3.8%; P < .05). They are less likely to report asthma symptoms (60.8% vs 74.4%; P < .01) and an emergency room visit in the past year (14.1% vs 21.1%; P < .01), yet more likely to report fair or poor perceived health status (25.0% vs 10.5%; P < .01). Multivariate models revealed that the relationship of immigrant status with health measures was complex. These models suggested that lack of insurance and poverty was associated with reduced access and utilization. Children in immigrant families were less likely to visit the emergency room for asthma in the past year (odds ratio 0.58, confidence interval, 0.36-0.93). Poverty was associated with having a limitation in function and fair or poor perceived health, whereas non-English interview language was associated with less limitation in function but greater levels of fair or poor perceived health.Clinicians should be aware of important barriers to care that may exist for immigrant families who are poor, uninsured, and non-English speakers. Reduced health care access and utilization by children with asthma in immigrant families requires policy attention. Further research should examine barriers to care as well as parental perceptions of health for children with asthma in immigrant families.

Abstract

Filipinos are the second largest Asian subgroup in the United States, but few studies have examined health and health care disparities in Filipino children. The objectives of this review are 1) to appraise current knowledge of Filipino children's health and health care and 2) to present the implications of these findings for research, clinical care, and policy.We identified articles for review primarily via a Medline search emphasizing the terms Filipino and United States crossed with specific topics in child and adolescent health that fall under one of Healthy People 2010's 28 focus areas.Filipino children are underrepresented in medical research. Studies that compare Filipino children and adolescents with white children or children of other Asian Pacific Islander subgroups suggest disparities with regard to gestational diabetes, rates of neonatal mortality and low birth weight, malnutrition in young children, overweight, physical inactivity and fitness, tuberculosis, dental caries, and substance abuse. Studies that compare Filipino adults with white adults describe adult Filipino health problems similar to those of Filipino children, including higher rates of diabetes, hypertension, and metabolic syndrome. Health care disparities remain to be determined.Health and health care disparities appear to exist for Filipino children, but more research is needed to confirm these findings. Practitioners serving this population need to consider social and cultural factors that can increase or diminish risk for health problems. There are priorities in research and policy that, if pursued, may improve the health care and health outcomes of Filipino children.

Preventing Obesity in Mexican-American Children and Adolescents. In Joint U.S.-Mexico Workshop on Preventing Obesity in Children and Youth of Mexican OriginInstitute of Medicine of the National Academies. The National Academies Press, Washington, D.C.,Trowbridge, R., Mendoza, F2007: 128-186

Abstract

To describe the sociodemographic differences among Mexican American children (first, second, and third generation), non-Hispanic black children, and non-Hispanic white children; to compare the health status and health care needs of Mexican American children (first, second, and third generation) with those of non-Hispanic black children and non-Hispanic white children; and to determine whether first-generation Mexican American children have poorer health care access and utilization than do non-Hispanic white children, after controlling for health insurance status and socioeconomic status.The Third National Health and Nutrition Examination Survey was used to create a sample of 4372 Mexican American children (divided into 3 generational groups), 4138 non-Hispanic black children, and 4594 non-Hispanic white children, 2 months to 16 years of age. We compared parent/caregiver reports of health status and needs (perceived health of the child and reported illnesses), health care access (usual source of health care and specific provider), and health care utilization (contact with a physician within the past year, use of prescription medications, physician visit because of earache/infection, and hearing and vision screenings) for different subgroups within the sample.More than two thirds of first-generation Mexican American children were poor and uninsured and had parents with low educational attainment. More than one fourth of first-generation children were perceived as having poor or fair health, despite experiencing similar or better rates of illnesses, compared with other children. Almost one half of first-generation Mexican American children had not seen a doctor in the past year, compared with one fourth or less for other groups. Health care needs among first-generation Mexican American children were lower, on the basis of reported illnesses, but perceived health status was worse than for all other groups. After controlling for health insurance coverage and socioeconomic status, first-generation Mexican American children and non-Hispanic black children were less likely than non-Hispanic white children to have a usual source of care, to have a specific provider, or to have seen or talked with a physician in the past year.Of the 3 groups of children, Mexican American children had the least health care access and utilization, even after controlling for socioeconomic status and health insurance status. Our findings showed that Mexican American children had much lower levels of access and utilization than previously reported for Hispanic children on the whole. As a subgroup, first-generation Mexican American children fared substantially worse than second- or third-generation children. The discrepancy between poor perceived health status and lower rates of reported illnesses in the first-generation group leads to questions regarding generalized application of the "epidemiologic paradox." Given the overall growth of the Hispanic population in the United States and the relative growth of individual immigrant subgroups, the identification of subgroups in need is essential for the development of effective research and policy. Furthermore, taking generational status into account is likely to be revealing with respect to disparities in access to and utilization of pediatric services.

Abstract

Latino families who express a higher degree of familism are characterized by positive interpersonal familial relationships, high family unity, social support, interdependence in the completion of daily activities, and close proximity with extended family members. Retention of cultural values, such as familism, may be linked to positive health outcomes; however, little is known about how families retain culture of origin values in the face of acculturation pressures. The current study explores acculturation influences as indexed by language preference and household education on maternal and child familism. Mothers and children of Mexican descent (fourth grade students) (n = 219) completed measures of demographics, household education, language preference, and familism. Three hypotheses were examined. First, we predicted that lower household education would be correlated with higher familism scores. However, contrary to our prediction, a higher familism score was significantly associated with a higher level of household education (p

Abstract

To evaluate the usefulness of the Pediatric Symptom Checklist (PSC) in identifying behavioral problems in low-income, Mexican American children.A cross-sectional study design was used to examine the PSC as a screening test, with the Child Behavior Checklist (CBCL) as the criterion standard.The study was conducted at a health center in a diverse low-income community. Patients Eligible patients were children and adolescents, 4 to 16 years of age, who were seen for nonemergent, well-child care. Of 253 eligible children during a 9-month study period, 210 agreed to participate in the study. There was a 100% completion rate of the questionnaires. The average age of the children was 7.5 years, and 45% were female. Ninety-five percent of patients were of Hispanic descent (Mexican American); 86% of families spoke only Spanish. Socioeconomic status was low (more than three fourths of families earned

Abstract

Latinos recently became the largest racial/ethnic minority group of US children. The Latino Consortium of the American Academy of Pediatrics Center for Child Health Research, consisting of 13 expert panelists, identified the most important urgent priorities and unanswered questions in Latino child health. Conclusions were drawn when consensus was reached among members, with refinement through multiple iterations. A consensus statement with supporting references was drafted and revised. This article summarizes the key issues, including lack of validated research instruments, frequent unjustified exclusion from studies, and failure to analyze data by pertinent subgroups. Latino children are at high risk for behavioral and developmental disorders, and there are many unanswered questions about their mental health needs and use of services. The prevalence of dental caries is disproportionately higher for Latino children, but the reasons for this disparity are unclear. Culture and language can profoundly affect Latino children's health, but not enough cultural competency training of health care professionals and provision of linguistically appropriate care occur. Latinos are underrepresented at every level of the health care professions. Latino children are at high risk for school dropout, environmental hazards, obesity, diabetes mellitus, asthma, lack of health insurance, nonfinancial barriers to health care access, and impaired quality of care, but many key questions in these areas remain unanswered. This article suggests areas in which more research is needed and ways to improve research and care of Latino children.

A book a day keeps the doctor away: A look at the implementation and effects of reach out and read, a pediatric clinic-based early literacy promotion programResources in EducationOrr JE, Baker S, Shirling E, Sanders L, Huffman LC, Mendoza FS2001

Abstract

To assess book-sharing activities within first-generation Hispanic immigrant families, and to assess the effect of pediatricians giving books to their patients.Survey.Convenience sample of 122 predominantly Hispanic immigrant parents of children aged 2 months to 5 years. Of these parents, 56 had received children's books from the pediatrician, and 66 had not.House staff continuity clinic at a university children's hospital.Frequent Book Sharing (FBS) was defined as a parent's reporting more than 3 days per week of sharing books with the child. Main independent variables included the following: (1) exposure to the Reach Out and Read program, defined as having received a children's book from the pediatrician; (2) socioeconomics, as measured by parents' years of education and Medicaid enrollment; (3) acculturation, as defined by 4 questions relating to parents' proficiency with the English language; (4) parent's country of origin; (5) parent literacy, as measured by a parent's reporting more than 3 days per week of reading alone; (6) parent's age; (7) marital status; (8) household size; (9) child's age; (10) child's sex.Ninety percent of the parents were born outside of the United States (71% in Mexico), 85% spoke Spanish in the home, and 63% had completed less than a high-school education. Seventy-five percent of children's medical insurance was provided by Medi-Cal (Medicaid), and 9% of children were uninsured. Sixty-seven percent spoke exclusively Spanish at home, and 84% of parents want their children to learn to read in both English and Spanish. High FBS was reported among parents whose children had received books from the physician when compared with parents whose children had received no books. The odds ratio (OR) was 3.62 (95% confidence interval [CI], 1.40-9.37; P

Nutritional Status of Immigrant ChildrenIn Children in Immigrant Families: Issues for California?s Future. California Policy Research Center, California Program on Access to Care and the UCLA Center for Health Policy ResearchMendoza FS2000: 11-12

From Generation to Generation: The Health and Well-Being of Children in Immigrant FamiliesBoard on Children, Youth, and Families, National Research Council, Institute of Medicine, National Academy PressCommittee member and Contributor1998

Measures of Health Status and Health Care Access for Mainland Puerto Rican Children: Results from the Hispanic Health and Nutrition Examination Survey.In C.G. Cole and G. Lamberty (eds.), Health and Development of Puerto Rican Mothers and Children in the MainlandMendoza F., Takata G.1994

Abstract

The dental restorative treatment needs of Mexican-American children, aged 1-17 years, were assessed from the 1982-83 Southwestern US Hispanic Health and Nutrition Examination Survey (HHANES). This report analyzed those needs and applied a dollar cost to them, using 1982 median fees of US general practitioners. The total estimated cost required to meet those needs for the population estimate of 3,396,770 children was $236,856,772 (95% CI: $198,575,174 to $275,138,370). The mean cost per child was $69.73 (SE: 5.75). Although a majority of the children had no unmet need, 15-, 16-, and 17-year-olds had extensive needs for crowns, endodontics, and prosthetic replacement of teeth, with accompanying high costs: mean total cost per examinee was $177 (SE: 28.97), $161 (SE: 32.20), and $237 (SE: 33.26), respectively. The treatment needs were compared with the previously published regional data from the 1979-80 NIDR survey, which used the same dental restorative treatment needs (DRTN) index. The findings indicated a great need for dental treatment among Mexican-American children that appeared to exceed that of the general school-aged population. Our analysis, in providing estimates of the cost of needed treatment, might be useful in planning dental treatment programs and in comparing surveys.

Abstract

The 1987 National Vital Statistics System and the Hispanic Health and Nutrition Examination Survey (1982 through 1984) were used to assess the health status of Mexican-American, mainland Puerto Rican, and Cuban-American children by examining the prevalences of pregnancy outcomes and chronic medical conditions. The low-birth-weight rate among Hispanics (7.0%) compared favorably with that of non-Hispanic whites (7.1%) despite the greater poverty and lower levels of education among Hispanics. When examined by Hispanic subgroup, however, significant differences were present, with mainland Puerto Ricans having the highest prevalences of low-birth-weight infants. Premature births were more common among all three Hispanic subgroups than among non-Hispanic whites. Mexican-American and Cuban-American children had a similar prevalence of (3.9% and 2.5%, respectively) chronic medical conditions compared with non-Hispanic white children; Puerto Rican children had a higher prevalence of chronic medical conditions (6.2%). When assessed by these health status indicators, Hispanic children seem to have a health status similar to non-Hispanic white children. However, mainland Puerto Rican children seem at greater risk for poor health, reflecting the US Hispanic population's heterogeneity. Health programs targeted at US Hispanics should appropriately consider these group differences.

Abstract

Height and weight data from the Mexican-American portion of the Hispanic Health and Nutrition Examination Survey (HHANES) are shown for children of ages 2 to 17 years and compared with data for non-Hispanic white children from the second National Health and Nutrition Examination Survey and with the National Center for Health Statistics (NCHS) reference curves. Differences in stature between the Hispanic Health and Nutrition Examination Survey and the reference populations were minor prior to adolescence and could be entirely attributed to the greater poverty of Mexican-Americans. However, differences increased during adolescence (ie, median stature was less than the 25th percentile of the NCHS reference population at 17 years of age) and, in contrast with earlier ages, were independent of poverty. Similar growth patterns were observed in samples of upper-class subjects from Mexico and Guatemala. Nonetheless, the extent to which the short stature of Mexican-American adolescents is genetic is unclear because there is an apparent time trend toward greater stature in the Mexican-American population. In conclusion, the NCHS reference curves are appropriate growth standards for preadolescent Mexican-American children. Whether they are valid for Mexican-American adolescents remains unclear.